Vitrectomy — Procedure Guide, Recovery & Risks | MyMedicPlus

Pars plana vitrectomy (PPV) is a microsurgical procedure that removes the vitreous gel — the clear jelly filling the posterior two-thirds of the eye — from the posterior segment, providing the vitreoretinal surgeon with direct access to the retina through the now-clear vitreous cavity. The vitreous is replaced during surgery with a balanced salt solution, air, an inert gas (sulphur hexafluoride SF6 or perfluoropropane C3F8), or silicone oil, depending on the underlying condition and the tamponade requirements for healing. Modern small-gauge (23–27 gauge) transconjunctival sutureless systems use micro-incisions of under 0.7 mm that self-seal without sutures, dramatically reducing post-operative inflammation, recovery time, and risk compared with older 20-gauge techniques. Vitrectomy is the primary surgical approach for all major posterior segment pathology including rhegmatogenous and tractional retinal detachment, full-thickness macular hole, epiretinal membrane (macular pucker), diabetic vitreous haemorrhage or tractional retinal detachment, endophthalmitis (intraocular infection requiring urgent intervention), dropped intraocular lens nucleus, and giant retinal tears requiring internal tamponade. Small-gauge sutureless vitrectomy systems — 23-gauge, 25-gauge, and 27-gauge — have transformed the procedure: smaller port diameters reduce surgical trauma, enable faster healing with self-sealing sclerotomies that do not require sutures in the majority of cases, and allow shorter operative times. Modern vitrectomy machines with high-speed cutters (up to 10,000 cuts per minute) and wide-angle visualisation systems provide unprecedented intraoperative access to the entire retinal surface.

Vitrectomy is indicated for retinal conditions requiring internal surgical access that cannot be managed with laser or external procedures alone. Primary indications include rhegmatogenous retinal detachment — particularly macula-involving, posterior, or multiple-break detachments; full-thickness macular holes causing central visual distortion and loss of fine detail; symptomatic epiretinal membranes causing metamorphopsia and reduced visual acuity despite functional disability; non-clearing vitreous haemorrhage from proliferative diabetic retinopathy or retinal vein occlusion obscuring vision for over 3 months; tractional retinal detachment from proliferative diabetic retinopathy threatening the macula; endophthalmitis requiring vitreous biopsy, washout, and intravitreal antibiotic injection; giant retinal tears; and dropped lens nucleus complicating phacoemulsification cataract surgery. Urgency is highest for macula-on retinal detachments (ideally repaired within hours to days to preserve central vision) and endophthalmitis (within 24–48 hours). The decision to operate is made by a vitreoretinal specialist based on clinical assessment and optical coherence tomography (OCT) imaging.

Vitrectomy is performed under local (peribulbar or retrobulbar block) or general anaesthesia. Three micro-incisions (sclerotomies) are created at the pars plana, 3.5–4 mm posterior to the limbus (the junction of cornea and sclera), through which a fibre-optic light pipe, an infusion cannula (maintaining intraocular pressure throughout surgery), and a vitreous cutter handpiece are introduced simultaneously. The high-speed vitreous cutter (up to 10,000 cuts per minute in modern systems) aspirates the vitreous in a controlled manner under direct visualisation through the operating microscope and wide-field viewing system. The retina is then inspected for breaks and vitreoretinal traction. For retinal detachment, retinal breaks are identified and sealed with laser photocoagulation or cryotherapy. Subretinal fluid may be drained internally. For macular holes, the internal limiting membrane (ILM) is peeled using fine end-grasping forceps after vital dye (indocyanine green or brilliant blue) staining. Following the surgical repair, the vitreous cavity is filled with a tamponade agent: air, short-acting gas (SF6 dissolves in 2–3 weeks), long-acting gas (C3F8 dissolves in 6–8 weeks), or silicone oil (requires surgical removal at 2–3 months). The micro-incisions are self-sealing and require no sutures in most cases. The sclerotomies are confirmed self-sealing at the end of the procedure by applying gentle pressure alongside each wound; any that leak are secured with a single 7-0 Vicryl suture.

Modern small-gauge vitrectomy achieves anatomical retinal reattachment in 85–95% of primary rhegmatogenous retinal detachments after a single procedure — outcomes equivalent or superior to scleral buckling without requiring external explant material. Full-thickness macular hole closure is achieved in 85–95% of primary cases with ILM peeling and gas tamponade, with significant improvement in visual acuity in 75–85% of patients. Visual gains are greatest when surgery is performed before the macula becomes detached or before significant photoreceptor atrophy develops. Epiretinal membrane peeling resolves metamorphopsia and improves visual acuity in 80% of patients. Rapid clearance of vitreous haemorrhage from diabetic retinopathy restores vision and enables laser treatment to be completed. The advent of sutureless microincision vitrectomy surgery (MIVS) with 25–27 gauge instrumentation has reduced post-operative discomfort, surgical time, and recovery significantly compared with older techniques.

Re-detachment of the retina occurs in 5–10% of cases after primary vitrectomy, most commonly from missed or new retinal breaks, proliferative vitreoretinopathy (PVR — fibrous membrane formation on the retinal surface causing traction), or inadequate tamponade. PVR is the leading cause of surgical failure requiring revision surgery. Accelerated posterior subcapsular cataract formation is the most common long-term complication — virtually universal in phakic patients within 2–3 years of vitrectomy due to increased oxidative stress from vitreous removal. Many surgeons combine phacoemulsification cataract extraction with vitrectomy in patients over 50 at the primary surgery. Raised intraocular pressure (IOP) is common transiently with gas or silicone oil tamponade and may require topical antiglaucoma treatment. Epiretinal membrane formation on the posterior retinal surface can recur. Suprachoroidal haemorrhage (bleeding between the choroid and sclera) is a rare but potentially blinding intraoperative complication. Endophthalmitis, though rare (under 0.1%), can cause devastating visual loss.

Following vitrectomy with gas tamponade, the specific positioning requirement is critical for success. Patients must maintain face-down posturing — head tilted so that the gas bubble rises to press on the macular repair site or retinal break — for 50 minutes out of every waking hour for 7–14 days. Failure to posture adequately significantly reduces the chance of macular hole closure and may compromise retinal reattachment. Face-down pillows and mirrors are provided by the surgical team. Air travel and travel to altitude are strictly contraindicated while any intraocular gas remains, as reduced atmospheric pressure causes rapid gas expansion, risking a dangerous IOP spike and acute angle-closure glaucoma — patients must carry a letter warning anaesthetists about the intraocular gas. Gas dissolves spontaneously: air within 1–3 days, SF6 within 2–3 weeks, C3F8 within 6–8 weeks, confirmed by reducing the internal bubble visible to the patient. Silicone oil requires planned surgical removal at 2–3 months. Antibiotic and anti-inflammatory eye drops are instilled 4 times daily for 4–6 weeks. Follow-up examinations are arranged at 1 week, 4 weeks, and 3 months to monitor retinal reattachment and visual recovery.